A few years ago, a staff pediatrician at my hospital asked me who ranked higher - a paramedic or an Emergency Medical Technician (EMT)? I remember thinking two things: first was the obvious "duh!", but the second was "hmm...maybe some things are not so obvious to non-Emergency Medicine (EM) physicians."
If you are already doing an EM rotation at an Emergency Department (ED), then chances are that EM is already established or is being established at that locale. Chances are, your ED is receiving ambulance traffic and of course you know the answer to the above question.
So why even talk about pre-hospital emergency medical services (EMS) at all? What does that have to do with your EM/ED rotation, or even with your future EM practice?
Receive your information about a patient directly from the ambulance personnel.
For one thing, it’s simply prudent and efficient. What was happening at the scene? Who called? Who else is coming? What did the EMS medics do or not do? What is the patient’s primary concern, and does that match or not match the ambulance crew’s primary concern? Much information can be lost or misconstrued if we solely rely on the nurses, even worse – on paper, to tell us the full story.
Watch the patient on the EMS gurney carefully
Often their facial mimics, gestures and the way they are looking around the ED will tell you a lot. Can they transfer to the ED bed themselves? What’s their body mechanics while doing that? There is much to learn here in just a few seconds – trust me. The patient may not end up being yours, but in a little bit of time, an hour or two, look them up on the ED board and see if your own initial impression was right: sick or not sick? Serious or so-so? Admitted or discharged? This is a critical skill to hone for any EM provider.
Anticipate EMS patient needs even before they are roomed.
While it is true that most of our ED patients are walk-ins, multiple analyses have shown in multiple locations around the world that the EMS patient population tend to be sicker. So this population is where some of those cool and awesome procedures that you want to see, learn or perform are often found. Healthy 18-year-old man, tall, suddenly short of breath while playing basketball with his friends – there is your chest tube arriving, see?
Your main task is to learn to comprehend the entire emergency care system. EM providers in EDs do not function in isolation. We are part of the emergency care continuum and should thus be those most proficient is seeing and knowing the big picture. EMS is the beginning of that picture.
EM physicians all around the world participate in pre-hospital work via multiple avenues: supporting public and sporting events, serving as cruise physicians, staffing ICU-ambulances and EMS support vehicles, flying on medical helicopters, writing EMS protocols, training paramedics and providing real-time phone, radio or teleconsultations. Chances are, you will too!
So while you are rotating at an ED, especially a foreign ED or one away from your home base, take a small effort to learn about the local EMS. Talk to the medics, talk to ED personnel taking EMS radio calls and look pertinent things up on the internet on your own (like local EMS protocols). Talk to the attending EM physicians in your ED – chances are, one of them is the local EMS guru!
Some simple things you may wish to focus on to gauge any EMS system anywhere
- Is there a single EMS emergency number for the public to call?
- Is there a centralized EMS dispatch? Are they Fire, Police or EMS-proper?
- Can an ambulance crew be re-directed away from the ED to take a patient to some alternative location or treat and leave the patient at home?
- Are there criteria for Trauma Center, Stroke Center and STEMI Center destinations? What about sick kids and neuro-trauma?
- Is there a global positioning system on the ambulances? Can they transmit EKGs or other information to the ED?
- Are there different types of ambulances, and different response types? For instance, when are two ambulances or an ambulance plus a fire engine sent to the same call?
- Who staffs the ambulance? Is it paramedics, EMTs, nurses, nurse practitioners or physicians? In what numbers? Are they understaffed?
- Is the paramedic scope of practice truly that of a paramedic? Can they intubate? Can they push IV medications or run drips?
- What medications and equipment do ambulances carry? Is there CPAP, LMAs, IO needles or devices? Are there automated chest compression devices (and does the literature support their use)?
- Are ambulances services public or private, or is there a mix? How are they funded?
- Who determines their number and distribution at a given geographic location? Is that enough?
- How are inter-facility transports handled? Is it the same ambulances who bring you the patients?
Finally, many an interesting medical student or resident research project began out of some EMS-related consideration or observation, so keep your eyes and ears open for those research ideas! Good luck!.
